From the Guidelines
A comprehensive cirrhosis workup should begin with a thorough clinical assessment, including a detailed history of alcohol use, risk factors for viral hepatitis, and physical examination for signs of liver disease, followed by initial laboratory tests and imaging studies, with MR elastography being the most accurate method for diagnosing liver fibrosis noninvasively, as recommended by the American College of Radiology 1. The initial laboratory tests should include a complete liver panel (ALT, AST, ALP, bilirubin, albumin), complete blood count, and coagulation studies (PT/INR). Abdominal ultrasound is the preferred initial imaging study to assess liver morphology and screen for portal hypertension, but it has limitations in diagnosing earlier stages of fibrosis and in patients with obesity and ascites. To determine etiology, test for hepatitis B and C viruses, and consider autoimmune markers (ANA, ASMA, AMA) if history suggests. Non-invasive fibrosis assessment using ARFI elastography or serum biomarkers (e.g., FIB-4, APRI) can help stage fibrosis, and MR elastography is the most accurate method for diagnosing liver fibrosis noninvasively, as it assesses the whole liver and can stage liver fibrosis 1. Some key points to consider in the workup include:
- Screening for hepatocellular carcinoma (HCC) with MRI or multiphase CT, especially in patients with obesity, NAFLD, and nodular cirrhotic livers, as US is limited in these patient groups 1.
- Assessing for varices with upper endoscopy if there's evidence of portal hypertension.
- Calculating MELD and Child-Pugh scores to assess disease severity and prognosis. The workup should be guided by the most recent and highest quality evidence, and MR elastography should be considered as the first-line imaging modality for diagnosing liver fibrosis noninvasively, due to its high accuracy and ability to stage liver fibrosis 1.
From the Research
Initial Workup for Cirrhosis
The initial workup for cirrhosis includes:
- Viral hepatitis serologies
- Ferritin
- Transferrin saturation
- Abdominal ultrasonography
- Complete blood count
- Liver function tests
- Prothrombin time/international normalized ratio, if not already ordered 2
Additional Testing
Additional testing is based on demographics and risk factors. Common serum and ultrasound-based screening tests to assess fibrosis include:
- Aspartate transaminase to platelet ratio index score
- Fibrosis 4 score
- FibroTest/FibroSure
- Nonalcoholic fatty liver fibrosis score
- Standard ultrasonography
- Transient elastography 2
Assessment of Liver Function
The assessment of liver function in cirrhosis should include:
- Structural assessment
- Functional assessment of both hepatic and non-hepatic tissue
- Haemodynamic assessment of portal hypertension 3
- Liver function tests such as serum bilirubin, liver enzymes, serum alkaline phosphatase, gamma glutamyl transpeptidase, serum albumin, and prothrombin time 3, 4
Blood-Based Algorithm for Diagnosing Compensated Advanced Chronic Liver Disease
A blood-based algorithm using fibrosis-4 (FIB-4) and von Willebrand factor/platelet count ratio (VITRO) can be used to identify compensated advanced chronic liver disease (cACLD) and stratify the risk of clinically significant portal hypertension (CSPH) 5
Evaluation of Abnormal Liver Tests
Abnormal liver tests can be evaluated using a systematic approach that includes:
- Detailed history gathering
- Alcohol use assessment
- Recognition of metabolic syndrome
- Identifying patterns of liver test abnormalities 6